Behavior Problems in Children and Adolescents With Chronic

Physical Illness: A Meta-Analysis

Martin Pinquart, PHD, and Yuhui Shen, MS
Department of Psychology, Philipps University

All correspondence concerning this article should be addressed to Martin Pinquart, Department of
Psychology, Philipps University, D-35032 Marburg, Germany. E-mail: pinquart@staff.uni-marburg.de
Received December 29, 2010; revisions received May 3, 2011; accepted May 15, 2011

Objective To examine the risk of emotional and behavioral problems among children with a chronic physi-
cal illness. Methods Random-effects meta-analysis was computed to integrate the results of 569 studies
that used the Child Behavior Checklist, Youth Self Report, and the Teacher Report Form. Results Young
people with a chronic physical illness have higher levels of internalizing (g ¼ .47 standard mean difference),
externalizing (g ¼ .22) and total behavior problems (g ¼ .42) than healthy peers. The largest differences
were found in parental ratings and the weakest differences in adolescent self-ratings. Strongest elevations of
internalizing problems were found for chronic fatigue syndrome and strongest elevations of externalizing
problems were observed for epilepsy and migraine/tension-type headache. Effects also varied by country and,
in part, by age, gender, year of publication, and study design. Conclusions The results call for regular
screens for psychological distress and referrals for mental health services, when needed.

Key words Achenbach System of Empirically Based Assessment; Child Behavior Checklist; chronic illness;
externalizing problems; internalizing problems; meta-analysis.

Epidemiological studies have shown that about 15% of chil-
dren and adolescents, on average, have a chronic physical
health condition (van der Lee, Mokkink, Grootenhuis,
Heymans, & Offringa, 2007). These conditions are risk fac-
tors for behavior problems (e.g., Barlow & Ellard, 2006).
Analyzing the prevalence of behavior problems of children
with chronic physical illness and identifying related risk
factors is of theoretical and practical relevance. First, it
helps to understand psychosocial consequences of chronic
physical diseases. Second, it provides valuable information
for clinicians regarding who should be screened for which
kind of problems. Third, it provides important information
about the need for preventing these problems as part of an
integrated treatment. Since many chronic diseases cannot
be cured, a main goal is to reduce the consequences of the
diseases on the lives of children and adolescents.
Multivariate approaches to child psychopathology
often distinguish between externalizing and internalizing
problems and disorders (Achenbach, 1991). Externalizing
problems include delinquent and aggressive behaviors, and
internalizing problems include somatic complaints, anxi-
ety, depression, and social withdrawal.
Elevated levels of internalizing as well as externaliz-
ing problems may be observed in children with chronic
physical illness (Barlow & Ellard, 2006; Lavigne & Faier-
Routman, 1992). Sources of elevated internalizing prob-
lems in children with a chronic physical illness may be
the perceived lack of control over the illness and its symp-
toms or progression (e.g., in epilepsy or sickle cell disease),
frightening symptoms (e.g., in the case of asthma or
epilepsy), restrictions in positive activities (e.g., due to hos-
pitalization), peer rejection (e.g., in the case of visible ab-
normalities, such as cleft lip and palate), as well as side
effects of therapy (e.g., in the case of radiation and chemo-
therapy of cancer patients). In addition, symptoms of the
physical illness, such as pain, may lead to elevated scores
of somatic complaints that are part of internalizing problem
clusters (Achenbach, 1991).

Journal of Pediatric Psychology 36(9) pp. 1003–1016, 2011

doi:10.1093/jpepsy/jsr042
Advance Access publication August 1, 2011
Journal of Pediatric Psychology vol. 36 no. 9 ß The Author 2011. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
1004 Pinquart and Shen
Externalizing problems may be elevated when the
physical illness affects brain function and the associated
behavioral regulation (e.g., in the case of epilepsy). In ad-
dition, externalizing problems may be a response to
illness-related frustrations, such as being teased by peers
(Reijntjes et al., 2010). However, some sources of internal-
izing problems (restrictions of positive activities, low con-
trol over symptoms or the course of the disease, overlap
with somatic symptoms of the disease) are probably more
widespread than the sources of externalizing problems,
possibly leading to greater effects of chronic illness on in-
ternalizing problems. Up to now, five meta-analyses have
assessed internalizing and externalizing problems of chil-
dren with chronic illness. A meta-analysis of 87 studies by
Lavigne and Faier-Routman (1992) found stronger ele-
vations of internalizing (d ¼ .55 SD units) than of exter-
nalizing problems (d ¼ .26) in children with chronic
physical illness. Young people with sensory and neuro-
logical disorders showed the highest elevation of overall
symptoms, but the authors did not compare specific
chronic illnesses with regard to externalizing and internal-
izing problems. More recently, McQuaid, Kopel, and
Nassau (2001), and Rodenburg, Stam, Meijer,
Aldenkamp, and Deković (2005) observed elevated levels
of internalizing (d ¼ 0.73–1.38) and externalizing problems
(d ¼ 0.35–0.81) in children with asthma and epilepsy, re-
spectively. Furthermore, Karsdorp, Everaerd, King, and
Mulder (2007) observed elevated levels of total behavior
problems (d ¼ .47), and of internalizing (d ¼ .47) and ex-
ternalizing problems (d ¼ .19) in children with congenital
heart disease. Finally, a meta-analysis of LeBovidge,
Lavigne, Donenberg, and Miller (2005) observed only ele-
vated levels of internalizing problems (d ¼ .47) but not of
externalizing problems (d ¼ .04) in young people with
arthritis.
These meta-analyses have limited test power for the
search of moderating effects of study characteristics.
Thus, the goal of the present meta-analysis was to compare
the levels behavior problems of children and adolescents
with different chronic physical illnesses to those of their
healthy peers and to identify moderating effects of study
characteristics. Since available measures of behavior prob-
lems differ with regard to the assessed dimensions, we fo-
cused on the instruments that have been most widely used
with young people with chronic illness—the Child
Behavior Checklist (CBCL—a parent report) as well as
the parallel Youth Self Report (YSR which is used in 11-
to 18-year-olds) and the Teacher Report Form (TRF;
Achenbach, 1991).
Influences of Study Characteristics
Specific expectations about effects of nine study character-
istics could be stated.
Internalizing Versus Externalizing Problems
In line with previous meta-analyses (Karsdorp et al., 2007;
Lavigne & Faier-Routman, 1992; LeBovidge et al., 2005;
McQuaid et al., 2001; Rodenburg et al., 2005), we ex-
pected to find higher levels of internalizing than of exter-
nalizing problems. Since the content of the Somatic
Complaints subscale overlaps with illness-specific somatic
symptoms (Perrin, Stein, & Drotar, 1991), we also ex-
pected to find the strongest effect size in this scale.
Informant
Studies on depression in children with chronic illness have
found higher between-group differences in parent-rated
symptoms than in self-rated symptoms of their children
(Bennett, 1994; Pinquart & Shen, in press). However,
Lavigne and Faier-Routman (1992) and Rodenburg et al.
(2005) did not find significant differences between child,
parent, and teacher reports of behavior problems, possibly
due to lack of statistical power. Based on a larger number
of studies, we wanted to test whether young people with
chronic illness show stronger elevations of parent-rated be-
havior problems than of self-rated behavior problems.
Type of Illness
We put our focus for analyzing further moderators on stud-
ies based on parental reports, as they comprise approxi-
mately 80% of the reported effect sizes. We expected the
strongest effect sizes for internalizing problems to be found
for those illnesses that are associated with a higher number
of stressors (such as activity restrictions, frightening symp-
toms, and lack of control over symptoms). The strongest
levels of externalizing problems were expected for illnesses
that affect brain function (epilepsy, headache, and spina
bifida).
Age
Karsdorp et al. (2007) only found elevated levels of behav-
ior problems of children with congenital heart disease in
older patients. We tested whether this result could be rep-
licated in the present meta-analysis.
Gender
In general, male adolescents show higher levels of external-
izing problems than their female peers, whereas the reverse
is found for internalizing problems (Steinberg, 2008).

If behavior problems are gender-specific responses to
illness-related stressors, these gender differences may be
accentuated in young people with chronic illnesses.
Country
On average, better medical and psychosocial services may
be available in industrial countries than in developing or
threshold countries. Therefore, we expected to find smaller
effect sizes in studies from industrialized countries.
Publication Status
As nonsignificant results may be less likely to be published
(Lipsey & Wilson, 2001), we wanted to test whether
unpublished studies (e.g., dissertations) would report
lower effect sizes than published studies.
Year of Publication
We expected to find lower between-group differences in
more recent studies because of progress in the treatment of
many diseases (e.g., Bleyer, 2002) and the development of
psychosocial services for young people with chronic illness.
Study Quality
Some clinical samples may over-represent highly distressed
young people seeking treatment for their chronic disease,
which is why we expected stronger between-group differ-
ences in clinical (convenience) samples than in random
community-based samples.
Exploratory Analysis of Other Moderators
Moderating effects of duration of illness, race/ethnicity,
target of comparison (test norms vs. healthy control group),
and sociodemographic matching of the patient and control
group were assessed exploratively, because no theory-based
expectations could be stated and/or because results from
previous meta-analyses are contradictory.
Methods
Sample
Studies were identified through electronic databases
(PSYCINFO, MEDLINE, Google Scholar, and PSYNDEX
[an electronic data base of psychological literature from
German-speaking countries] search terms: [chronic illness
or disability or AIDS or arthritis or asthma or cancer or
chronic fatigue syndrome or cleft or cystic fibrosis or deaf
or diabetes or epilepsy or headache or heart disease or
hearing impairment or HIV or inflammatory bowel disease
or kidney disease or liver disease or migraine or rheuma-
tismor sickle cell or spina bifida or visual impairment] and
Behavior Problems and Chronic Illness 1005
[Child Behavior Checklist or Youth Self Report or Teacher
Report Form or Achenbach System of Empirically Based
Assessment]) and cross-referencing. Criteria for inclusion
of studies in the present meta-analysis were:
(a) they used the CBCL (CBCL 4–18, CBCL 1½–5),
YSR or TRF;
(b) the studies were published since the development
of the scales and before May, 2011;
(c) they compared levels of behavior problems between
young people with chronic physical illnesses and
healthy peers or test norms, or they provided suffi-
cient information for a comparison with established
normative data (e.g., by reporting standardized
T-scores, raw score, and percentage of respondents
above defined cut-offs);
(d) mean age of participants was  18 years; and
(e) standardized between-group differences in behavior
problems were reported or could be computed.
Documentation of a physician’s diagnosis within each
study was not a requirement because of the need to include
broad-based survey studies for which medical documenta-
tion might not have been available. In order to include
studies from different regions of the world, we also did
not limit the included studies to those written in English.
Studies published in Chinese, Dutch, English, German,
Korean, Portuguese, Spanish, and Turkish were included.
Available unpublished studies (e.g., dissertations) were
also included. Studies were excluded if the samples of chil-
dren were identified because they had ‘‘clinical’’ levels of
behavior problems.
We identified 693 studies. After screening and assess-
ing for eligibility, we were able to include 569 studies in
the meta-analysis. A flow chart of the search for studies is
provided in Appendix A1, and the studies included are
listed in the Appendix A2 (see Supplementary Data).
Most of the studies were done in industrialized countries.
However, we were able to include studies from Brazil,
China, the Dominican Republic, India, Egypt, Malaysia,
Thailand, and Turkey. Information from the World Bank
(2010) was used for coding countries as developed or de-
veloping/threshold countries.
We entered the number of patients and control group
members, mean age, percentage of girls and percentage of
members of ethnic minorities, country of data collection,
year of publication, type of illness, duration of illness, the
sampling procedure (1 ¼ probability samples, 0 ¼ conve-
nience samples), use of a control group (0 ¼ yes, 1 ¼ com-
parison with test norms), equivalence of patient and control
group (1 ¼ yes, 2 ¼ not tested, 3 ¼ no), the rater of behavior
1006 Pinquart and Shen
problems (1 ¼ adolescent, 2 ¼ parent, 3 ¼ teacher), and
the standardized size of between-group differences in
total problems, internalizing problems, externalizing prob-
lems, withdrawn behavior, somatic complaints, anxiety/
depression, delinquent behavior, aggressive behavior, social
problems, thought problems, and attention problems. If
between-group differences were provided for several sub-
groups within the same publication (e.g., for different ill-
nesses), we entered them separately in our analysis instead
of entering the global association. If data from more than
one rater were collected, we entered the effect sizes sepa-
rately. All studies were coded by the first author, and one-
third of them also by the second author. A mean inter-rater
reliability of 94% (range 89–100%) was established.
Differences were resolved by discussion.
Statistical Integration of the Findings
Calculations for the meta-analysis were performed in five
steps, using random-effects models and the method of
moments (Lipsey & Wilson, 2001).
1. We computed effect sizes d for each study as the
difference in behavior problems between the
sample with chronic illnesses and the control
sample divided by the pooled SD. If the authors
only provided test scores for children and adoles-
cents with chronic illness, we used the norms
from the test manuals for comparison. If separate
CBCL scores were reported for mothers and
fathers, we averaged both scores. Outliers that
were more than 2 SD from the mean of the effect
sizes were recoded to the value at 2 SD, based on
Lipsey and Wilson (2001).
2. Using Hedges’ g, effect size estimates were adjusted
for bias due to overestimation of the population
effect size in small samples. Hedges’ g leads
to smaller estimations of the effect size than
Cohen’s d, but the difference declines with
increasing sample size and is less than 1% for
sample sizes of 80 and larger.
3. Weighted mean effect sizes and 95% confidence
intervals (CIs) were computed. The significance
of the mean was tested by dividing the weighted
mean effect size by the standard error of the
mean. To interpret the practical significance of the
results, we used Cohen’s criteria (Cohen, 1988):
Differences of g ¼ 0.20–0.49 are small, of
g ¼ 0.50–0.79 medium, and of g  0.8 large.
4. Homogeneity of effect sizes was computed by use
of the Q-statistic.
5. In order to test the influence of moderator
variables, we used an analogue of an analysis of
variance and weighted ordinary least squares
regression analyses. In univariate analyses, a signif-
icant Qb-score indicates heterogeneity of the effect
sizes between the compared conditions. Which
conditions differ is tested by comparing the 95%
CIs. Differences between two conditions are signif-
icant if CI of two effect sizes do not overlap
(Lipsey & Wilson, 2001). Statistical power analysis
was computed based on Hedges and Pigott
(2001).
Results
Data from 51,422 children and adolescents with chronic
illnesses were included. The largest subgroup had asthma
(n ¼ 13,793), followed by epilepsy (n ¼ 6,815), cancer
(n ¼ 3,936), heart diseases (n ¼ 2,692), diabetes (n ¼ 2,136),
hearing impairments (n ¼ 2,136), sickle cell disease
(n ¼ 1,897), cleft lip and palate (n ¼ 1,817), arthritis
(n ¼ 1,746), migraine/tension headache (n ¼ 1,188),
kidney/liver disease (n ¼ 937), HIV-infection (n ¼ 771),
spina bifida (n ¼ 700), cystic fibrosis (n ¼ 674), inflamma-
tory bowel disease (n ¼ 579), chronic fatigue syndrome
(n ¼ 289), and visual impairment (n ¼ 186). The partici-
pants had a mean age of 10.6 years (SD ¼ 6.8 years);
45.9% of them were girls and 43.7% were members of
ethnic minorities.
Power analysis indicates that the probability was
.8 that the study will detect a small effect sizes of d ¼ .20.
Levels of Internalizing, Externalizing, and Total
Problems
When summing up all effect sizes, we observe higher levels
of total problem behavior in children with chronic illness
as compared to healthy peers or test norms (g ¼ .42, 95%
CI 0.38–0.45, Z ¼ 24.93, p < .001). Similarly, levels of in-
ternalizing problems (g ¼ .47, CI 0.44–0.50, Z ¼ 29.73,
p < .001) and externalizing problems (g ¼ .22, CI .19–
.25, Z ¼ 14.76, p < .001) were elevated in children with
chronic illness.
According to Cohen’s criteria for interpreting effect
sizes (Cohen, 1988), effects were small to moderate
when using parental and teacher ratings. In studies using
adolescent ratings, effects on total problems and internal-
izing problems were small, and no significant effect size
was found for externalizing problems (Table I).
 Behavior Problems and Chronic Illness 1007

720

953

588
0
0
0

661
376
593
45,447

1,037
As shown by the Qb -statistics, the effect sizes of total

k0
problems differed between raters (parent rating: gP ¼ .46,
teacher rating: gT ¼ .37, child/adolescent rating: gC ¼ .17;

66.03*

64.86
48.68
40.26
82.59
109.38
55.09

55.40

41.72
56.01
29.97
Qw Table I). Effect sizes for internalizing problems
(gP ¼ .51, gT ¼ .38, gC ¼ .27) and externalizing problems
Adolescent reports

(gP ¼ .24, gT ¼ .27, gC ¼ .01) also differed between

.08
.26
.22
.27
.36
.45
.67
.37

.39
.32
.39
95%-CI

raters. The nonoverlap of the CI indicates that elevations

of internalizing (gP ¼ .51 vs. gC ¼ .27) and externalizing

Note. k ¼ number of studies; g ¼ effect size; 95% CI ¼ lower and upper limits of 95% CI; Q ¼ test for homogeneity of effect sizes between conditions (Qb) and within conditions (Qw); k0 ¼ fail-safe N.
.10
.06
.02
.07
.18
.22
.38
.14

.12
.09
.11
problems (gP ¼ .24, gC ¼ .01) as well as total problems
(gP ¼ .46, gC ¼ .17) in children with chronic illnesses
.17***
.27***
.34***
.53***
.25***

.26***
.21***
.25***
were more pronounced in studies that used parental re-
g

.01
.10
.10
ports than in studies using child self-reports. In addition,
the non-overlap of the CI indicates that effect sizes for total
73
88
46
47
46
72
41
44

45
41
43
k

symptoms (gT ¼ .37 vs. gC ¼ .17) as well as externalizing

problems (gT ¼ .27 vs. gC ¼ .01) were larger if teacher
717
590
580

184
490

588
2,470
5,724

1,691

1,329

1,291
k0

reports rather than child self-reports were used.

Significant rater effects were also observed for most
55.55
41.59
23.95
13.72
16.83
77.11
19.81
27.05

20.52
20.42
19.60
Qw

subscales. Effect sizes of withdrawn behavior (gP ¼ .57 vs.

gC ¼ .34), anxiety/depression (gP ¼ .53 vs. gC ¼ .25), delin-
Teacher reports

quent behavior (gP ¼ .33 vs. gC ¼ .10), aggressive behavior

.48
.48
.66
.78
.63
.37
.58
.62

.86
.76
.90
95%-CI

(gP ¼ .40 vs. gC ¼ .10), social problems (gP ¼ .60 vs.

.27
.27
.34
.33
.31
.18
.21
.27

.49
.40
.52

gC ¼ .26), thought problems (gP ¼ .48 vs. gC ¼ .21), and

attention problems (gP ¼ .66 vs. gC ¼ .25) were larger for
.37***
.38***
.50***
.56***
.47***
.27***
.39***
.44***

.67***
.58***
.71***

parental reports than for adolescent reports. Effect sizes for

g

aggressive behavior (gT ¼ .44 vs. gC ¼ .10), social problems

(gT ¼ .67 vs. gC ¼ .26), thought problems (gT ¼ .58 vs.
60
71
26
22
25
73
20
25

25
21
26
k
Table I. Behavior Problems in Children With Chronic Illness: Variations by Source of Information

gC ¼ .21), and attention problems (gT ¼ .71 vs. gC ¼ .25)

were also significantly larger for teacher reports than for
333,069
454,638
104,432
205,813
81,840
99,375
34,343
66,732

78,944
57,668
125,992
k0

adolescent reports (Table I).

The non-overlap of the 95% CIs indicates that eleva-
tions of internalizing problems were more pronounced than
576.27
642.86
252.03
295.44
252.57
605.20
247.60
306.06

237.35
210.72
266.57
Qw

elevations of externalizing problems, although these differ-

Parent reports

ences were only significant for parent ratings (gP ¼ .51 vs.
.49
.54
.62
.78
.57
.27
.39
.45

.66
.53
.72

.24) and adolescent self-ratings (gC ¼ .27 vs. .01).

95%-CI

In order to address the potential for a file drawer prob-

.42
.47
.52
.66
.48
.21
.28
.35

.54
.43
.60

lem a fail-safe n calculation was conducted, based on

Rosenthal (1991). Results revealed that 34,343–454,638
.46***
.51***
.57***
.72***
.53***
.24***
.33***
.40***

.60***
.48***
.66***

studies with null results would be required to negate the

g

range of effect sizes for the CBCL observed (Table I).

The use of the CBCL in patients with chronic illness
559
618
258
298
252
596
248
287

215
221
244
k

has been criticized because the somatic complaints scale

may assess, at least in part, illness-specific symptoms
Differences

29.69***
26.51***

19.132**
28.57***

20.19***

22.43***
19.32***
27.18***
12.76**

11.50**
between

7.20*

which would cause an overestimation of total and inter-

Qb
raters

nalizing problems (Perrin et al., 1991). In fact, the non-

*p < .05, **p < .01, ***p < .001.

overlap of the CI shows that the effect size for parental

Externalizing problems
Internalizing problems

ratings of somatic complaints (gP ¼ .72) is significantly

Somatic complaints

Attention problems
Anxious/depressed

Thought problems
Social problems

higher than for the other subscales of internalizing prob-

Other problems
Total problems

lems (withdrawal: gP ¼ .57, anxiety/depression: gP ¼ .53;

Withdrawn

Delinquent
Aggressive

Table I). No such differences were found for adolescent

and teacher ratings. In order to estimate whether the re-
sults would differ when excluding the somatic complaints
1008 Pinquart and Shen
subscale, we computed a modified total problems score of
the CBCL by averaging the effect sizes of all subscales
except somatic complaints. Similarly, we computed a mod-
ified Internalizing Problems score by averaging the effect
size of the withdrawn behavior and anxiety/depression.
This procedure was possible for about 50% of the available
studies. As indicated in the Supplementary Appendix 3,
the modified scales showed moderate effects for total prob-
lems (gP ¼ .51) and internalizing problems (gP ¼ .53), and
their CI overlapped with the CIs of the original scales in
Table I. Thus, the results were quite similar for the original
and modified scales.
Comparison of Illnesses
The next analysis focused on the comparison of the differ-
ent kinds of illnesses. Separate effect sizes were reported if
at least five studies were available for a particular illness.
Since studies on vision loss and hearing loss did not report
separate effect sizes for the associated different diseases, we
used only sum categories of vision and hearing loss. The
following analyses are based on parental reports of their
children’s behavior.
As indicated by the Q-statistics (Table II, first line), the
effect sizes for internalizing, externalizing, and total prob-
lems varied between diseases. Statistically significantly ele-
vated levels of total behavior problems were observed for all
assessed diseases except for cleft lip and palate and HIV
infection. Elevated levels of internalizing problems were
found for all diseases except cleft lip and palate. With
regard to total problems, moderate effect sizes were found
for migraine/tension-type headache (gP ¼ .75), kidney/liver
disease (gP ¼ .70), epilepsy (gP ¼ .63), chronic fatigue
syndrome (gP ¼ .62), asthma (gP ¼ .61), hearing impair-
ment (gP ¼ .56), and spina bifida (gP ¼ .50). According to
Cohen’s (1988) criteria, elevations of internalizing prob-
lems were large in children with chronic fatigue syndrome
(gP ¼ 1.42). In addition, moderate elevations were observed
with regard to migraine/tension headache (gP ¼ .77), epilepsy
(gP ¼ .66), chronic kidney/liver disease (gP ¼ .67), asthma
(gP ¼ .63), inflammatory bowel disease (gP ¼ .60), and
spina bifida (gP ¼ .59). Small effect sizes are listed in
Table II.
Elevated levels of externalizing problems in children with
chronic illness were only observed for 10 out of 17 diseases/
disabilities (Table II). Interestingly, a negative effect size was
observed for externalizing problems of children with cleft
lip and palate (gP ¼ .24): Parents of these children re-
ported fewer symptoms than parents of healthy children.
The effect sizes for most illness groups were homoge-
neous. However, heterogeneity beyond sampling error was
observed with regard to the levels of total problems in
young people with epilepsy and kidney/liver diseases,
levels of internalizing problems in children with arthritis,
heart diseases, and kidney/liver diseases, as well as levels of
externalizing problems of young patients with chronic fa-
tigue syndrome, kidney/liver diseases, and the sum cate-
gory of other illnesses.
Scores on the CBCL subscales for the individual dis-
eases are reported in Table III. Effect sizes for all subscales
varied between disease groups. According to Cohen’s cri-
teria (1988), large effect sizes were found for spina bifida
(attention problems: gP ¼ 1.00, social problems: gP ¼ .94,
withdrawal: gP ¼ .93), epilepsy (attention problems: gP ¼
1.07, social problems: gP ¼ .88), chronic fatigue syndrome
(anxious-depressiveness: gP ¼ .99, somatic complaints:
gP ¼ 1.35), HIV-infection/AIDS (withdrawal: gP ¼ 1.44, de-
linquency: gP ¼ .84), inflammatory bowel disease (with-
drawal: gP ¼ 84, somatic complaints, gP ¼ 1.47), kidney/
liver disease (somatic complaints: gP ¼ .88, attention prob-
lems: gP ¼ .86), asthma (somatic complaints: gP ¼ 1.02),
arthritis/rheumatism (somatic complaints: gP ¼ .92), and
sickle cell disease (somatic complaints: gP ¼ .84).
Moderator Effects of Sociodemographic
Characteristics
In order to compare our results on age differences with the
study by Karsdorp et al. (2007), we divided the sample into
the same age groups. The Q-statistics indicates significant
age differences for the three problem scales. The non-
overlap of the CI indicates that effect sizes were smaller
in children under the age of 6 years than in the other age
groups for total problems (gP ¼ .19 vs. gP ¼ .48), internal-
izing (gP ¼ .18 vs. gP ¼ .48–.55), and externalizing prob-
lems (gP ¼ .06 vs. gP ¼ .25–.28; Table II). The effect sizes
within each age group were homogeneous, except the total
score and the internalizing score in the youngest group.
In order to explore moderating effects of gender, we
trisected the sample according to the percentage of female
participants. Significant gender differences were observed
with regard to total and externalizing problems. The non-
overlap of the CI indicates that the levels of total (gP ¼ .58)
and externalizing problems (gP ¼ .38) showed significantly
higher elevations if the samples were comprised of
two-thirds or more male participants.
Furthermore, we observed significant differences be-
tween children from developing and developed countries
for all three problem scales. Stronger elevations of prob-
lems were found in children with chronic illnesses living in
developing/threshold countries (gP ¼ .47–.65) than in de-
veloped countries (gP ¼ .22–.49). However, no significant
moderating effects were found for ethnicity and duration of
illness.
Table II. Association of Study Characteristics With Elevated Levels of CBCL Behavior Problems in Children With Chronic Illness

Total problems Internalizing problems Externalizing problems

k g 95%-CI Q k g 95%-CI Q k g 95%-CI Q

Kind of illness/disability 107.79***a 150.78***a 89.93***a

Arthritis/Rheumatism 27 .20* .04 .36 31.31b 33 .48*** .34 .62 48.32*b 31 .13 .01 .26 37.62b
Asthma 55 .61*** .51 .72 50.43b 64 .63*** .53 .72 58.29b 58 .29*** .20 .36 49.89b
b b
Cancer 59 .29*** .19 .39 39.24 69 .34*** .25 .43 59.77 64 .06 .03 .15 42.22b
b b
Chronic fatigue syndrome (CFS) 10 .62*** .34 .91 11.46 9 1.42*** 1.11 1.73 0.56 7 .09 .23 .40 14.74*b
b b
Cleft lip and palate 27 .04 .11 .19 43.32 28 .05 .20 .09 18.34 26 .24*** .38 .10 22.68b
Cystic fibrosis 18 .27** .07 .46 15.49b 15 .37*** .16 .58 14.65b 15 .14 .06 .34 9.20b
Diabetes 33 .30*** .16 .43 27.61b 41 .40*** .27 .52 36.43b 41 .26*** .14 .38 27.64b
b b
Epilepsy 74 .63*** .54 .72 100.93** 71 .66*** .57 .75 71.73 68 .37*** .29 .46 73.83b
b b
Hearing impairment 16 .56*** .27 .65 13.69 17 .31** .13 .49 10.16 18 .34*** .18 .51 13.53b
b b
Heart disease 37 .42*** .30 .55 32.15 31 .44*** .31 .58 48.64* 29 .24*** .10 .37 26.60b
b b
HIV infection/AIDS 9 .19 .06 .45 7.82 11 .27* .04 .50 10.91 10 .19 .04 .41 3.94b
b b
Inflammatory bowel disease (IBD) 10 .30* .05 .56 7.43 13 .60*** .38 .82 8.31 10 .04 .19 .29 11.05b
b b
Kidney/liver disease 22 .70*** .52 .88 41.29** 24 .67*** .50 .85 38.26* 21 .34** .16 .51 38.87**b
Migraine/tension-type headache 17 .75*** .56 .95 8.48b 25 .77*** .62 .93 31.74b 21 .36*** .20 .52 15.49b
Sickle cell disease 10 .38*** .16 .61 4.39b 16 .48*** .29 .67 17.96b 20 .26** .09 .42 29.42b
b b
Spina bifida 7 .50* .16 .84 1.53 10 .59*** .33 .84 5.68 11 .32** .09 .55 8.43b
b b
Visual impairment 6 .48* .14 .82 2.88 6 .33 .00 .67 1.59 6 .33* .00 .65 3.26b
c b b
Other illnesses/ mixed samples 122 .51*** .44 .59 133.17 135 .54*** .47 .61 133.83 137 .32*** .25 .38 168.35*b
a a
Duration of illness 1.53 2.91 3.44a
b b
<Mean (5.7 years) 129 .49*** .42 .57 170.58** 134 .59*** .51 .67 180.81** 127 .30 .23 .37 145.20b
b b
>Mean 125 .43*** .35 .50 87.87 134 .49*** .41 .57 87.58 127 .19 .12 .27 110.77b
Mean age 17.68***a 30.88***a 10.09**a
<6 years 43 .19** .06 .32 60.83*b 43 .18* .05 .30 73.59**b 42 .06 .06 .18 56.43b
b b
6–10 years 169 .48*** .41 .54 153.46 178 .48*** .42 .54 155.39 178 .28 .22 .34 185.51b
b b
>10 years 321 .48*** .43 .53 335.19 372 .55*** .51 .60 371.78 352 .25 .20 .29 333.60b
a a
Percentage of girls 8.11* 1.50 13.65***a
b b
<33.3% 103 .58*** .49 .66 93.98 115 .56*** .47 .64 107.92 115 .38*** .30 .46 126.51b
b b
33.3–66.6% 330 .43*** .38 .48 348.79 359 .50*** .46 .55 370.23 347 .22*** .18 .26 330.71b
b b
>66.6% 70 .44*** .33 .55 71.34 87 .55*** .45 .65 87.94 80 .20*** .10 .29 84.85b
Percentage of members of 0.27a 3.52a 0.00a
ethnic minorities
<Mean 74 .42*** .33 .51 84.01b 97 .52*** .44 .60 119.44b 85 .18*** .11 .26 99.00b
b b
>Mean 66 .45*** .36 .55 64.38 88 .41*** .33 .49 72.93 87 .18*** .11 .26 78.46b
(continued)
Behavior Problems and Chronic Illness
1009
 1010

Table II. Continued

Pinquart and Shen

Total problems Internalizing problems Externalizing problems

k g 95%-CI Q k g 95%-CI Q k g 95%-CI Q

a a
Country 9.53** 4.43* 15.39***a
Developing/threshold countries 55 .64*** .51 .74 68.12b 49 .65*** .53 .77 59.35b 46 .47*** .35 .58 54.46b
Developed countries 504 .44*** .40 .47 501.72b 569 .49*** .46 .53 562.16b 550 .22*** .19 .26 540.50b
a a
Publication status 0.01 2.85 0.56a
b b
Unpublished 20 .44** .25 .63 14.29 21 .35*** .17 .54 15.85 18 .31** .13 .50 11.93b
b b
Published 539 .46*** .42 .49 557.59 597 .51*** .48 .55 607.17 578 .24*** .21 .27 586.04b
a a
Year of publication/presentation 3.29 2.59 30.16**a
b b
<1990 60 .56*** .44 .68 54.47 76 .58*** .47 .68 58.78 83 .47*** .38 .57 65.90b
b b
1990–1999 181 .44*** .37 .50 175.43 191 .52*** .46 .58 155.78 183 .25*** .19 .31 168.01b
2000–2011 317 .45*** .40 .50 339.80b 351 .49*** .44 .53 409.09*b 330 .19*** .15 .23 363.38b
Target of comparison 3.21a 0.01a 7.94*a
b b
Control group 243 .49*** .44 .55 235.44 271 .50*** .45 .56 264.66 260 .30* .25 .34 217.51b
b b
Test norms 316 .43*** .38 .47 336.47 347 .51*** .46 .56 358.23 336 .20* .16 .24 379.89*b
a a
Equivalence of patients and 4.16 4.19 28.66***a
control group/condition
No 21 .35*** .16 .54 14.56b 23 .34*** .17 .52 17.74b 22 .10** .04 .17 .64.41***b
b b
Yes 143 .52*** .44 .59 147.47 162 .54*** .48 .61 173.75 151 .28*** .25 .32 398.31***b
Not tested 387 .45*** .40 .49 406.92b 428 .51*** .47 .55 429.28b 418 .20*** .19 .22 822.93***b
Representativeness of the sample 0.92a 3.17a 0.83a
b b
Convenience sample 535 .46*** .42 .50 524.72 593 .51*** .48 .55 601.90 573 .24*** .21 .27 576.42b
(clinical sample)
Random sample/community 23 .37** .19 .55 45.59**b 23 .36*** .18 .53 18.78b 21 .32*** .15 .48 18.96b
sample
Note. k ¼ number of studies; g ¼ effect size; 95% CI ¼ lower and upper limits of 95% CI; Q ¼ test for homogeneity of effect sizes.
a
Test of the homogeneity of effect sizes between conditions.
b
Test of homogeneity of effect sizes within the condition. Significant score indicate heterogeneity.
c
This category includes allergies, anorectal malformation, burns, cerebral palsy, cloacal extrosophy, congenital Durchenne muscular dystrophy, endocrine disorders, hemifacial microsomia, hypospadias, hypothyroidism, congenital/ac-
quired limb loss, dwarfing, imperforate anus, Langerhans Cell Histiocytosis, limb deficiency disorders, lung diseases, Lyme disease, mastocytosis, metabolic disorders, mierotia, mitochondrial disorder, neurofibromatosis, neurological
dysfunction, neuronal ceroid lipofuscinoses, obesity, orthopedic diseases, phenylketonuria, pulmonary hypertension, sagrital craniostynosis, short statue, spinal muscular atrophy, stroke, thalassemia major, Turner syndrome, and
velo-cardio-facial syndrome.
*p < .05, **p < .01, ***p < .001.
 Behavior Problems and Chronic Illness 1011

Table III. Comparison of Subscales by Kind of Illness

Withdrawn Somatic complaints Anxious/depressed Delinquent

(Qb ¼ 58.81***) (Qb ¼ 70.13***) (Qb ¼ 42.45***) (Qb ¼ 47.30***)

k g 95%-CI k g 95%-CI k g 95%-CI k g 95%-CI

Arthritis/rheumatism 10 .56*** .31 .80 11 .92*** .63 1.21 7 .49*** .21 .77 7 .10 .19 .39
Asthma 9 .46*** .20 .72 15 1.02*** .76 1.28 14 .64*** .46 .82 14 .44*** .22 .66
Cancer 25 .50*** .35 .66 30 .77*** .60 .94 20 .47*** .31 .64 23 .13 .03 .29
Chronic fatigue syndrome 9 .77*** .49 1.05 10 1.35*** 1.02 1.68 7 .99*** .67 1.31 8 .03 .32 .25
Kidney/liver disease 18 .76*** .58 .94 17 .88*** .65 1.11 19 .68*** .51 .85 13 .31** .09 .52
Cleft lip and palate 22 .41*** .26 .56 22 .45*** .25 .64 23 .32*** .18 .47 16 .31*** .14 .48
Cystic fibrosis 4 .06 .49 .37 6 .67*** .26 1.09 3 .18 .35 .70 6 .68*** .34 1.03
Diabetes 12 .40*** .20 .61 13 .65*** .40 .91 13 .43*** .24 .63 14 .21* .02 .40
Epilepsy 35 .74*** .63 .86 38 .78*** .63 .92 36 .63*** .51 .74 35 .48*** .37 .59
Hearing impairment 8 .38*** .16 .60 9 .29* .01 .57 8 .36** .14 .59 7 .34** .11 .57
Heart disease 8 .32** .10 .54 7 .40* .09 .71 8 .21 .01 .43 4 .10 .21 .41
HIV infection/AIDS 1 1.44*** .64 2.24 4 .06 .43 .55 3 .62** .17 1.06 2 .84** .27 1.40
IBD 5 .84*** .52 1.15 5 1.47*** 1.06 1.88 4 .60*** .27 .93 3 .20 .17 .57
Kidney/liver disease 18 .76*** .58 .94 17 .88*** .65 1.11 19 .68*** .51 .85 13 .31** .09 .52
Migraine 12 .39*** .20 .59 17 .78*** .56 1.00 10 .51*** .30 .72 11 .07 .13 .27
Sickle cell disease 7 .46** .15 .75 10 .84*** .53 1.14 3 .22 .16 .59 5 .26 .06 .59
Spina bifida 4 .93*** .55 1.31 3 .59* .06 1.12 1 .30 .33 .94 3 .31 .11 .73
Visual impairment 3 .26 .22 .75 5 .28 .19 .75 2 .14 .47 .75 5 .14 .24 .51
Other illnesses 66 .61*** .52 .70 76 .64*** .54 .75 71 .57*** .48 .66 72 .43*** .34 .52
Aggressive Social problems Attention problems Thought problems
(Qb ¼ 51.87***) (Qb ¼ 99.19***) (Qb ¼ 89.33***) (Qb ¼ 55.81***)

k g 95%-CI k g 95%-CI k g 95%-CI k g 95%-CI

Arthritis/rheumatism 6 .45** .12 .77 6 .11 .19 .41 7 .16 .16 .49 8 .33* .06 .60
Asthma 19 .29** .09 .49 10 .05 .19 .29 15 .26* .02 .50 12 .28* .06 .49
Cancer 26 .24** .08 .40 20 .58*** .40 .76 19 .44*** .24 .64 18 .27*** .11 .43
Chronic fatigue syndrome 8 .11 .42 .19 6 .21 .15 .57 5 .54* .13 .95 5 .41* .06 .75
Cleft lip and palate 20 .25** .08 .42 17 .51*** .34 .69 15 .50*** .29 .71 15 .47*** .30 .63
Cystic fibrosis 6 .47* .11 .83 3 .31 .23 .86 4 .74** .25 1.23 6 .33* .02 .65
Diabetes 14 .28** .08 .49 13 .24* .03 .44 13 .41*** .18 .65 14 .23** .06 .40
Epilepsy 39 .62*** .50 .74 35 .88*** .76 1.00 42 1.07*** .94 1.19 38 .74*** .64 .84
Hearing impairment 9 .41*** .18 .64 7 .55*** .28 .81 10 .62*** .38 .86 7 .55*** .44 .77
Heart disease 7 .14 .11 .40 6 .49*** .21 .76 8 .48** .22 .75 3 .41** .10 .73
HIV infection/AIDS 3 .10 .37 .57 3 .28 .16 .72 3 .62* .11 1.13 2 .53* .01 1.05
IBD 4 .42* .04 .80 2 .25 .24 .73 1 .00 .71 .71 2 .43* .04 .83
Kidney/liver disease 18 .70*** .50 .89 14 .64*** .43 .86 16 .86*** .64 1.08 13 .40*** .20 .59
Migraine 11 .27* .05 .49 11 .40*** .19 .61 10 .41*** .16 .66 11 .31*** .13 .49
Sickle cell disease 9 .30* .01 .58 5 .19 .13 .52 6 .33 .08 .74 5 .33* .01 .65
Spina bifida 4 .56** .16 .97 3 .94*** .52 1.36 4 1.00*** .56 1.43 2 .40 .05 .84
Visual impairment 5 .40* .01 .80 2 .42 .23 1.08 5 .53* .09 .97 3 .36 .09 .81
Other illnesses 79 .44*** .35 .52 52 .83*** .72 .93 63 .70*** .60 .81 58 .54*** .46 .63
Note. k ¼ number of studies; g ¼ effect size; 95% CI ¼ lower and upper limits of 95% CI; Qb ¼ test for homogeneity of effect sizes across the different diseases.
*p < .05, **p < .01, ***p < .001.

Moderator Effects of Characteristics of the
Publication
The Qb-statistics indicates that published and unpublished
studies did not differ in effect size. As the CBCL was in-
troduced 30 years ago, we compared results from these
three decades. The Qb-statistics indicates that the effect
size for externalizing problems, but not for internalizing
and total problems, differ by year of publication. As
shown by the nonoverlap of the CI, elevations of external-
izing problems of children with chronic illness were
1012 Pinquart and Shen

stronger in studies that were published before 1990
(gP ¼ .47) than in later studies (gP ¼ .19–.25).
Furthermore, the Qb-statistics indicates that levels of
externalizing, but not of internalizing and total problems,
vary by the target of comparison. Significantly stronger
between-group differences in externalizing problems were
observed in studies that used a healthy control group
(gP ¼ .30) than in studies that compared behavior problems
of children with chronic illnesses to test norms (gP ¼ .20).
The effect size of the latter group was heterogeneous.
Finally, effect sizes for externalizing problems varied
by the sociodemographic equivalence of the patient group
and control group. The nonoverlap of the CI indicates that
significantly weaker effect sizes were observed in studies
with nonequivalent control groups (gP ¼ .10) than in other
studies (gP ¼ .20–.28). However, the effect sizes did not
vary by the representativeness of the samples. Most effect
sizes of the subgroups were homogeneous. Nonetheless,
the test for heterogeneity was significant for the levels of
total problems in random samples.
We also ran all analyses with the modified total prob-
lems and internalizing problems scale (Appendix A3). The
results were very similar to the findings with the original
scales (e.g., mean difference for total problems gp ¼ .51,
internalizing problems: gp ¼ .53). Only the moderating
effect of age on the level of internalizing problems was
not replicated in that analysis.
Because some moderator variables may be correlated,
we concluded our investigation by testing whether the uni-
variate moderator effects could be replicated in multivariate
analysis. Only those moderators that were significant in at
least one univariate analysis were included. In order to
compare the diseases with the largest univariate effect sizes
(asthma, chronic fatigue syndrome, epilepsy, kidney/liver
disease, or migraine/tension-type headache) against the
other chronic conditions, a dummy variable was created
for the type of illness. As shown in Table IV, all univariate
moderator effects remained significant.
Discussion
The present study found elevated levels of behavior prob-
lems in children and adolescents with chronic physical
illnesses. On average, elevations of internalizing problems,
social problems, attention problems, and thought prob-
lems were larger than elevations of externalizing problems.
The effect sizes varied between the types of illnesses as well
as raters of behavior problems, country and, in part, by age,
gender, year of publication, study design, and equivalence
of patient and control group. The discussion will be orga-
nized according to the order of the research questions.
Levels of Internalizing, Externalizing, and
Total Problems
We observed stronger elevations of internalizing problems
than of externalizing problems of children and adolescents
with chronic physical illness. This difference cannot be ex-
plained by the fact that the internalizing score includes so-
matic complaints which may reflect illness-specific somatic
symptoms (Perrin et al., 1991). First, our meta-analysis
showed that the main results remain unchanged when
excluding the somatic complaints subscale. Note that
other correcting procedures of individual studies, such
as deleting other ambiguous items, led to similar results

Table IV. Multivariate Analysis of Moderating Effects of Study Characteristics (Multiple Linear Regression Analysis)

Total problems Internalizing problems Externalizing problems

B b Z B b Z B b Z

Kind of illness (2 ¼ asthma/CFS/epilepsy/migraine/ .17 .22 10.11*** .25 .26 6.46*** .14 .15 3.70***
tension-type headache, 1 ¼ others)
Mean age (1 ¼ lower than 6 years, 2 ¼ others) .36 .22 10.88*** .31 .18 4.53*** .17 .11 2.64**
Percentage girls (2 ¼ larger 33%, 1 ¼ others) .11 .09 4.28*** .09 .08 1.99* .16 .15 3.76***
Country (2 ¼ developed country, 1 ¼ developing/ .04 .05 2.56* .11 .13 3.35*** .13 .17 4.13***
threshold country)
Year of publication (1 ¼ before 1990, 2 ¼ others) .13 .08 3.80*** .04 .02 0.58 .23 .17 4.13***
Target of comparison (2 ¼ test norms, 1 ¼ healthy .02 .03 1.22 .00 .00 0.07 .09 .11 2.55*
control group)
Equivalence of patients and control condition .07 .03 1.37 .14 .06 1.53 .20 .10 2.32*
(1 ¼ no, 2 ¼ yes/not tested)
(Constant) .04 0.29 .16 0.56 .57 2.14*
R2 .12 .13 .14
n 493 548 528
Note. *p < .05, **p < .01, ***p < .001.

(e.g., Gleissner et al., 2008). Second, similar differences are
found when comparing levels of anxiety/depression
and withdrawn behavior with delinquent and aggressive
behavior. The difference indicates that sources of internal-
izing problems (e.g., restrictions of positive activities) may
be more widespread and/or may have stronger effects on
children with chronic physical illness than sources of
externalizing problems.
The analysis of the CBCL subscales indicated that, in
addition to somatic problems, children with chronic illness
are particularly at increased risk for attention and social
problems. Attention problems are, in part, consequences
of physical diseases, as in the case of epilepsy and chronic
headache (Hernandez, Sauerwein, Jambaqué, de Guise,
Lussier, & Lortie, 2003). In addition, thinking or worrying
about ones’ illness may impair their attention. Social prob-
lems refer to being too dependent upon others, not getting
along with peers or getting teased (Achenbach, 1991).
Elevations of these symptoms indicate that chronic ill-
nesses often impair peer relations and that they may also
impair the development of autonomy.
The present meta-analysis showed that adolescents do
not only report fewer behavior problems than their parents,
but also that similar differences exist when comparing
teacher and adolescent reports. As externalizing problems
can often be easily observed by parents or teachers, adult
reports on externalizing behaviors may, therefore, be re-
garded as quite objective (Frick, Barry, & Kamphaus,
2009). Our results may indicate that children with chronic
illness tend to underreport their symptoms, for example,
because they want to present themselves as healthy func-
tioning individuals (Huberty, Austin, Harezlak, Dunn, &
Ambrosius, 2000). Alternatively, parents and teachers may
underestimate the ability of the children to adapt toward
their illness. For example, caring for a child with chronic
illness causes parental distress (e.g., Ashkani, Dehbozorgi,
& Tahamtan, 2004) which could lead to biased estimations
of child problems (Youngstrom, Loeber, & Stouthamer-
Loeber, 2000).
Because the YSR—in contrast to the CBCL—was only
used with 11-year-olds and older adolescents, differences
between studies with the CBCL/TRF and the YSR might
also reflect different age ranges studied. However, as the
total, internalizing and externalizing CBCL scores of 11-year-
olds and older adolescents were significantly higher than the
YSR scores, the diverging age ranges of both instruments
cannot explain the observed rater differences.
Comparison of Illnesses
Our results indicate that elevated levels of internalizing
problems are observed in children with most chronic
Behavior Problems and Chronic Illness 1013
physical illnesses whereas elevations of externalizing prob-
lems are rather illness-specific. Most illnesses with the
strongest elevations of externalizing problems, i.e. epilepsy,
migraine/tension-type headache, and hearing impairment,
are always or often associated with impaired brain func-
tion. Neuroimaging studies have identified frontal lobe
brain abnormalities in patients with epilepsy and migraine
(e.g., Herrman et al., 2002; Schmitz et al., 2010). These
abnormalities are associated with executive function defi-
cits, which could affect the inhibition of externalizing prob-
lems. Side effects of medications, such as corticosteroids,
may in part explain elevated externalizing problems among
children with kidney and liver diseases (Soliday, Grey, &
Lande, 1999). The observed lower level of externalizing
problems in children with cleft lip and palate as compared
to healthy controls or test norms are difficult to interpret
because the subscales of delinquent and aggressive behav-
iors showed elevated scores. More research is needed before
definite conclusions can be drawn.
Differences between illnesses in the levels of inter-
nalizing problems were impressive. The largest effect size
was observed for chronic fatigue syndrome which may, in
part, be based on a symptom overlap of tiredness, unspe-
cific pain, sleep problems, and other somatic symptoms.
However, large elevations of internalizing problems per-
sisted after eliminating the somatic complaints subscale
(Appendix 3). Fatigue is also likely to interfere with ma-
ny positive aspects of daily life which may cause internaliz-
ing problems, such as withdrawal or depressed symptoms.
Interestingly, young people with chronic fatigue syndrome
did not show elevated levels of externalizing problems,
possibly because being tired inhibits such behaviors.
While children with chronic fatigue syndrome had
specific behavior problems, young people with migraine/
chronic-tension type headache and epilepsy showed above-
average levels of externalizing and internalizing problems.
Above-average levels of internalizing problems in these ill-
nesses may be based on restrictions of positive activities,
lack of perceived control over symptoms, and changes of
the brain. For example, epileptic activity in certain areas of
the brain directly causes paroxysmal anxiety (Beyenburg,
Mitchell, Schmidt, Elger, & Reuber, 2005).
Although the effect sizes of most diseases were homo-
geneous, they varied in particular between studies on
kidney/liver disease. This heterogeneity is probably based
on the fact that the specific illnesses within this group were
quite heterogeneous, for example, when needing organ
transplantation or showing a less severe disease.
In addition to the analysis of externalizing and inter-
nalizing problems, our study also analyzed problems in the
fields of attention, thought, and social relations. Changes
1014 Pinquart and Shen
in brain function could explain the observed high levels of
attention problems in children with epilepsy and spina
bifida. For example, Hernandez et al. (2003) observed
that especially abnormities of the frontal lobe of patients
with epilepsy were associated with attention problems.
Changes in the brain and the associated externalizing prob-
lems may also contribute to the high levels of social prob-
lems that were found in children with epilepsy. Observed
high levels of social problems in children with spina bifida
may be affected by the high levels of social withdrawal
which inhibits the development of peer-relations.
Moderator Effects of Sociodemographic
Characteristics
While in a meta-analysis on congenital heart disease
Karsdorp et al. (2007) had found lower levels of behavior
problems in children younger than 6 years than in those
older than 10 years, our study found that the youngest
group also differed from 6 to 10-year-olds. Below-average
levels of behavior problems in younger children with
chronic illness may indicate that some negative psychoso-
cial consequences of their illness do not yet appear that
early, such as being bullied by class mates.
Interestingly, we observed larger effect sizes for total
and externalizing problems in studies with higher percent-
ages of boys, whereas levels of internalizing problems did
not increase significantly in the case of a higher percentage
of girls. Thus, our results indicate that boys are more likely
to react toward their illness with externalizing symptoms,
possibly because this behavior is more consistent with the
male gender role (Steinberg, 2008). Studies not specific to
chronic physical illnesses have shown that gender differ-
ences in externalizing problems emerge, on average, earlier
than gender differences in internalizing problems (Steinberg,
2008). This could lead to the observed lack of moderating
effect of gender on the level of internalizing symptoms.
Characteristics of the Publication
The expected larger effect sizes of older studies were only
observed with regard to externalizing behavior. This result
may indicate that more progress has been made in the
prevention or treatment of externalizing rather than inter-
nalizing problems. In fact, in the last two decades more
studies on the prevention of externalizing problems have
been published than on the prevention of internalizing
problems (e.g., Röhrle, 2007). Alternatively, the effect of
time of measurement might also be based on the use of
different test norms. However, a supplementary analysis
showed that larger elevations of externalizing problems
are also found in older studies that compared children
with chronic illness with a healthy control group (gp ¼ .60
vs. gp ¼ .21/gp ¼ .09, Q(2,327) ¼ 53.11, p < .001).
We only found weak evidence for the suggested higher
effect sizes in studies that compared children with chronic
illnesses to healthy peers rather than test norms. Probably
children with severe chronic physical illnesses were under-
represented in the normative samples of the CBCL so that
similarities between the normative samples and healthy
control groups prevail.
Strengths and Limitations
Compared to previous meta-analyses on behavior problems
with chronic illness, we were able to include a much larger
data set. In order to collect a representative sample of
studies, we also did not limit our analysis to studies pub-
lished in English. This allowed for comparing a much larger
number of chronic illnesses and for assessing a broader
range of moderator variables.
Nonetheless, some limitations have to be mentioned.
First, the available cross-sectional data did not allow for
testing whether behavior problems were the consequences
of the physical illness or whether some of these problems
developed independently or even before the diagnosis of a
chronic physical disease. However, we were able to show
that children with chronic physical illness are at increased
risk for these problems. Second, only a few studies were
available for some kinds of illnesses, such as HIV-infection/
AIDS and visual impairment. Third, due to space limita-
tions, we did not include data on social competence that
are also assessed with the CBCL. Fourth, we limited our
analysis to the CBCL scales that have most often been used
in studies on chronic illness. Too few studies were available
for the DSM-oriented CBCL scales that were introduced by
Achenbach, Dumenici, and Rescorla (2003). Fifth, in order
to address the critique by Perrin et al. (1991) on the use of
the somatic complaints subscale with people with chronic
illness, we had to use a crude estimation of the corrected
internalizing and total problems. Finally, we did not ana-
lyze whether similar results would be found when using
other screening measures for behavior problems.
Conclusions
Despite these limitations, several conclusions can be drawn
from this meta-analysis. First, we conclude that elevated
levels of internalizing and total problems are observed in
almost all chronic illnesses. However, the level and profile
of behavior problems (e.g., whether internalizing and/or
externalizing problems are elevated) varies between dis-
eases. Second, the present meta-analysis highlights that

elevated levels of problems are also found in other areas,
such as attention or social problems, whereas many studies
focus exclusively on the internalizing and externalizing
scores of the CBCL. Third, the inclusion of the somatic
complaints subscale is unlikely to cause a serious bias when
working with total problem scores and internalizing prob-
lem scores of children with chronic illness. Nonetheless,
we agree with Perrin et al. (1991) that the results from
somatic complaints scale would be difficult to interprete
in this group of children. Fourth, due to the systematic
differences between results from adolescent self-reports
and parent/teacher reports, we recommend the use of dif-
ferent sources of information. If researchers or clinicians do
not want to overlook patients with elevated levels of behav-
ior problems, they should not rely exclusively on patient
self-reports. Fifth, we conclude that boys and girls with
chronic physical illness should routinely be screened for
internalizing problems whereas boys would be the main
target for screening for externalizing problems, given the
observed gender differences. Sixth, the observed elevated
levels of behavior problems call for a multidisciplinary team
approach wherein medical and psychosocial personnel es-
tablish a collaborative treatment approach. In addition to
treating the somatic disease, psychosocial interventions are
needed for preventing and treating behavior problems. For
example, Perrin, MacLean, Gortmarker, and Asher (1992)
have shown that a stress management intervention reduced
the level of behavior problems of young asthma patients.
Seventh, given the higher levels of behavior problems
among children with chronic physical illnesses from devel-
oping/threshold countries, more psychosocial services
aimed at preventing or treating these problems are needed
in these countries. Finally, future research should analyze
the interplay of processes that mediate the effect of chronic
physical illness on different forms of behavior problems.
Such studies would be helpful for identifying starting
points of interventions.
Supplementary Data
Supplementary data available at JPEPSY online.
Conflicts of interest: None declared.
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